Get the free Patient Referral for Spravato® Treatment

This document serves as a referral form for patients seeking treatment with SPRAVATO® (esketamine) nasal spray for treatment-resistant depression (TRD) or major depressive disorder (MDD) with acute suicidal ideation. The form captures patient information, medical history, and refers contacting healthcare providers while including crucial prescribing information, dosage guidelines, and potential side effects associated with the treatment.

How to fill out patient referral for spravato

How to fill out patient referral for spravato

1. Obtain the patient’s medical history and current conditions relevant to depression or treatment-resistant depression.
2. Complete the patient referral form provided by the treatment facility offering Spravato.
3. Provide patient information including their name, date of birth, and contact details.
4. Include any relevant diagnostic codes or notes from the patient's healthcare provider.
5. Indicate the rationale for referral, specifying the patient's treatment history and why Spravato is being considered.
6. Ensure all required signatures are completed, including those of the referring physician.
7. Submit the completed referral form to the treatment facility and keep a copy for your records.

Who needs patient referral for spravato?

1. Patients suffering from treatment-resistant depression who have not responded to other conventional antidepressant therapies.
2. Individuals diagnosed with major depressive disorder who meet the specific criteria set forth by the treatment facility for Spravato administration.
3. Patients who have been evaluated by a healthcare provider and deemed appropriate candidates for Spravato treatment.

For pdfFiller’s FAQs

How can I edit patient referral for spravato from Google Drive?

People who need to keep track of documents and fill out forms quickly can connect PDF Filler to their Google Docs account. This means that they can make, edit, and sign documents right from their Google Drive. Make your patient referral for spravato into a fillable form that you can manage and sign from any internet-connected device with this add-on.

How do I edit patient referral for spravato in Chrome?

Download and install the pdfFiller Google Chrome Extension to your browser to edit, fill out, and eSign your patient referral for spravato, which you can open in the editor with a single click from a Google search page. Fillable documents may be executed from any internet-connected device without leaving Chrome.

How do I complete patient referral for spravato on an Android device?

Use the pdfFiller Android app to finish your patient referral for spravato and other documents on your Android phone. The app has all the features you need to manage your documents, like editing content, eSigning, annotating, sharing files, and more. At any time, as long as there is an internet connection.

What is patient referral for spravato?

Patient referral for Spravato is the process by which healthcare providers refer patients for treatment with Spravato, a nasal spray used for treatment-resistant depression.

Who is required to file patient referral for spravato?

Healthcare providers, such as psychiatrists or primary care physicians, are typically required to file patient referrals for Spravato.

How to fill out patient referral for spravato?

To fill out a patient referral for Spravato, providers need to complete a referral form that includes patient information, medical history, and the reason for referral.

What is the purpose of patient referral for spravato?

The purpose of patient referral for Spravato is to assess eligibility for the treatment and ensure appropriate management of treatment-resistant depression.

What information must be reported on patient referral for spravato?

Patient referrals for Spravato must report information such as patient demographics, treatment history, current medications, and any relevant medical conditions.